- The changing of a tracheostomy tube in the school setting should be considered an emergency situation
- Any concern that the situation is potentially life-threatening requires the activation of the EMS/911 system while the procedure is being performed.
- The two most common emergency scenarios are:
- accidental decannulization; and
- tracheostomy tube obstruction unrelieved by reasonable suction attempts.
Obstruction can be caused by thick secretions/mucous plugging, foreign body, or airway granuloma tissue. Airway granuloma tissue can persist to obstruct a new tracheostomy tube, resulting in the highest degree of medical emergency.
Considerations:
- When caring for a student who has a tracheostomy, the nurse should always know the reason for the tracheostomy, the child’s underlying health conditions and whether the child needs the tracheostomy to breathe
- The changing of a tracheostomy tube in the school setting should be considered an emergency situation
- Any concern that the situation is potentially life-threatening requires the activation of the EMS/911 system while the procedure is being performed.
- The two most common emergency scenarios are:
- accidental decannulization; and
- tracheostomy tube obstruction unrelieved by reasonable suction attempts.
Obstruction can be caused by thick secretions/mucous plugging, foreign body, or airway granuloma tissue. Airway granuloma tissue can persist to obstruct a new tracheostomy tube, resulting in the highest degree of medical emergency.
Supplies:
Emergency Travel Bag Equipment:
The essential equipment to be kept with the student at all times is as follows:
- gloves
- portable oxygen ( if ordered)
- appropriate size Ambu-bag facemask (for emergencies when unable to reinsert a new tracheostomy tube)
- portable suction machine that can operate with battery or electricity
- sterile suction catheters
- sterile saline vials
- water-based lubricant
- two spare tracheostomy tubes — one the size the student currently uses and one that is a size smaller in the event that the tube needs to be changed and there is difficulty passing it through the stoma
- obturator, if applicable
- spare tracheostomy ties
- blunt scissors
- emergency phone numbers
- pulse oximeter — may be optional if student is not on oxygen or mechanical ventilation
Additional Needed Supplies:
- Stethoscope
- Medical tape
- Personal protective equipment
- goggles
- mask
- gloves
- Activate EMS/911
- Reassure student
- Wash hands, if student’s condition permits
- Assemble equipment as student’s condition permits or utilize equipment in emergency travel bag
- If ordered, place pulse oximeter on student’s finger, toe or ear lobe during and after the procedure
- Ensure the presence of another responsible adult, preferably another nurse if available, to assist with stabilizing the tracheostomy tube
- Put on gloves, goggles, and mask
- Have adult assisting with procedure put on gloves, goggles, and mask
- Suction the student’s tracheostomy tube, if indicated (see Tracheal Suctioning-Clean Technique)
- If able, position the student supine on the floor with a shoulder roll to gently hyperextend the neck
- Open the new tracheostomy tube kit that is the same size as is currently in the student
- Have the size smaller new tracheostomy tube readily available if needed
- If new tube is not available, clean the old tube as possible
- Take care to not touch the curved part of the tracheostomy tube
- If the tube has an obturator, be sure the obturator is in the tube
- Lubricate the distal end of the new tracheostomy tube with water-based lubricant return it to the clean package that it was sealed in
- Remove tracheostomy mask, artificial nose or ventilator connection, as necessary
- Give student two to four breaths with resuscitation bag
- If unable to pass suction catheter, do not attempt to give breaths to a plugged trach. CHANGE THE TRACH TUBE
- Have adult assisting with procedure hold old tracheostomy tube in place
- Assure tracheostomy tube cuff has been fully deflated, if applicable
- Deflate the cuff per manufacturer’s instructions
- Remove or cut old tracheostomy ties
- With one hand remove the old tracheostomy tube and set it out of the way
- Insert new tube
- If tube does not have an obturator, insert new tube at a right angle to the stoma, rotating it downward as it is inserted
- If tube has an obturator, insert tube straight into stoma
- Immediately remove the obturator and insert inner cannula (if trach tube has inner cannula)
- Note many pediatric trach tubes do not have an inner cannula
- Immediately remove the obturator and insert inner cannula (if trach tube has inner cannula)
- Insertion of new tube should take no longer than 30 seconds
- Have adult assisting with the procedure hold the new tracheostomy tube in place
- Administer a minimum of three breaths with a manual resuscitator bag
- Secure the new tracheostomy tube in place by fastening the tracheostomy ties:
- If this is a cuffed tracheostomy tube, inflate at this time per manufacturer’s instructions
- Re-attach tracheostomy mask, artificial nose or ventilator connection, as necessary
- Position the student comfortably and observe to ensure he or she remains stable on their baseline level of supplemental or ventilator support (if any)
- Continue the respiratory assessment, using pulse oximetry, if available, until EMS has arrived
- Discard used equipment per school policy
- Remove gloves
- Wash hands
- Document assessment, intervention and outcomes in student’s healthcare record
- Notify parents/guardian and medical provider that student required a tracheostomy change procedure
- Replenish supplies in emergency travel bag
If unable to replace tracheostomy tube:
- Reposition the student and re-attempt to place the tube
- If unsuccessful, attempt to place the smaller tube
- If unable to place a size smaller tube, assess child’s respiratory status to determine the need for rescue breathing
- If rescue breathing is needed
- Open the natural airway
- Be aware that some patients may not have a natural airway due to surgical procedures or anatomical abnormalities
- Tape over the tracheal stoma
- Give breaths using a manual resuscitation bag with a facemask
- Open the natural airway
- If rescue breathing is not needed and child’s respiratory status is stable
- Observe the child and call 9ll for assistance.
- If rescue breathing is needed
References:
American Thoracic Society. (2000). Care of the child with a chronic tracheostomy. American Journal of Respiratory & Critical Care Medicine, 1, 297-308.
Bowden, V. R., & Greenberg, C. S. (2012). Pediatric nursing procedures (Third Edition). Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins.
Children’s Hospital of Wisconsin. (2006). Tracheostomy Cares and Trach Tube Changes: Policy and Procedure.
Connecticut State Department of Education. (2012). Clinical Procedure Guidelines for Connecticut School Nurses. Available at:
http://www.sde.ct.gov/sde/lib/sde/pdf/publications/clinical_guidelines/clinical_guidelines.pdf
Hootman, J. (1996). National Association of School Nurses. Quality Nursing Interventions in the School Setting.
Porter, S., Haynie M.D., Bierle, T., Caldwell, T. & Palfrey, J. (1997). Children and Youth Assisted by Medical Technology in Educational Settings. Guidelines for Care. Second Edition. Paul H. Brookes Publishing Co., P.O. Box 10624, Baltimore, MD 21285-0624
Acknowledgment of Reviewers:
Cynthia C. Griffith, RN, BSN
Nurse Clinician
Tracheostomy/Home Ventilator Program
Children’s Hospital of Wisconsin
Cecilia Lang, MSN, CCRN, PNP-BC
Tracheostomy/Home Ventilator APN
Children’s Hospital of Wisconsin
Carole Wegner, MSN, RN
Clinical Nurse Specialist
Tracheostomy/Home Ventilator Program
Children’s Hospital of Wisconsin
Page last updated: November 10, 2015
Page last reviewed: November 10, 2015